Anaesthesiologic management of a parturient with a known antiphospholipid syndrome

Transcription

1 Anaesthesiologic management of a parturient with a known antiphospholipid syndrome Pascal Vuilleumier Universitätsklinik für Anästhesie und Schmerztherapie

2 Case presentation: Mrs A. B Early monday morning, phone call from the midwives: Mrs A. B. needs a cesarean delivery in the next 30 minutes because of foetal distress Fraxiparine 0.6ml bid, last dose 12 h ago 100 mg Aspirin per day Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 2

3 Case presentation: Mrs A. B Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 3

4 Present history 2nd pregnancy, 33 5/7 weeks gestation Intrauterine growth retardation with pathological FHR monitoring Antenatal corticosteroid therapy given Mild excentric mitral insufficiency Known antiphospholipid-antibody syndrome since 2005 with: Left deep vein thrombosis and central pulmonary thromboembolism 11/2003 Postpartal peripheric pulmonary thromboembolism with lung infarction despite treatment with Fraxiparin 0,6 ml 2*/day 13 month before Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 4

5 Anaesthesiologic management Decision of general anaesthesia Induction and intraoperative course uneventful Uterotomy and delivery whithout problems, APGAR 9/10/10 and normal umbilical ph values At the end of the cesarean delivery the uterine tonus is good, there is no bleeding, extubation is smooth Mother and baby are well Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 5

6 Postoperative management Goal: Establishment of therapeutic anticoagulation as quick as possible Start Heparin IU/24 H immediately after umbilical ligature Uneventful adaptation of the newborn and no postpartal bleeding But Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 6

7 First postoperative day 24H after C-section: acute retrosternal pain with irradiation in the left arm, resistant to nitroglycerine The EKG shows ST-elevation in the inferior leads The initial Troponin is normal Angio-CT scan shows no lung embolism Transthoracic ECHO: inferobasal hypokinesia, right and left vertricules are normal in size MI unchanged Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 7

8 Further treatment and evaluation She is transferred to the ICU for rhythm monitoring 6 hours after the beginning of symptoms pain vanishes, but heart enzymes rise A coronarography is performed immediately Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 8

9 Coronarography Subacute myocardial infarction with occlusion of a sidebranch of the 1. Marginal, successful aspiration and PTCA Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 9

10 48H later The clinical course in the ICU is favorable and she is transferred back to the women s ward on day 2 Histology of the aspired thrombus reveals placental tissue Suspicion of patent foramen ovale, evaluation for a possible percutaneous closure after clinical stabilisation Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 10

11 Evolution on day 2-4 Ongoing haemoglobin fall with final Hb of 61g/l despite 4 blood concentrates Hemodynamics just stable The FAST -scan of the abdomen detects free liquid in the peritoneum The ongoing blood loss, the positive fast-scan and the hemodynamics warrant an exploratory laparotomy Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 11

12 Exploratory laparotomy Stable intraoperative progress, lavage, surgical hemostasis, need of 4 blood concentrates and 2 fresh frozen plasma, no clear bleeding source identified Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 12

13 Day 5 Back to the women s ward, there is negligable free liquid in the peritoneum and the Hb remains stable The problems at that time: baby-blues abdominal pain and problems finding the good words Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 13

14 Cardiologic work-up The search of a PFO is negative with TEE and a new coronarography The differential diagnosis is another shunt or histological misdiagnosis Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 14

15 Further investigations Because there are no therapeutic consequences in the absence of a PFO there are no further cardiologic investigations On day 5 appearance of psychomotor restlesness and on the following night one episode of hallucination The neurologist demands an MRI Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 15

16 Day 5-6: MRI Multiple acute cerebral ischemic lesions Subacute and old cortical lesions Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 16

17 Day 11 New cerebral episode with a transitory motor hemisyndrome on her right side and retrosternal pain The CT-Scan shows no haemorrhage The retrosternal pain is a new episode of cardiac ischemia while being fully anticoagulated The treatment consists of maintenance of full anticoagulation and conservative support She leaves hospital on day 21 with Marcoumar and lowdose Aspirin Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 17

18 Antiphospholipid syndrome What did we do wrong? Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 18

19 Antiphospholipid syndrome Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 19

20 Clinical manifestations Red flag symptoms Unexplained DVT or PE<50y Stroke <50y TIA<50y Thrombosis at unusual site Unexplained foetal loss >10 weeks Severe or early pre-eclampsia Severe intrauterine growth restriction Pre-eclampsia with severe tc-penia Cardiac valve disease Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 20

21 Antiphospholipid syndrome, foetal effects Antiphospholipid antibodies can directly bind to trophoblast cells and cause: Direct cellular dammage Defective invasiveness of trophoblastic cells Activation of complement at the foetomaternal interface This results in an impared foetomaternal interface: Early miscarriage Pre-eclampsia Placental infarction with» Intrauterine growth restriction» Intrauterine foetal death Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 21

22 Definition Systemic autoimmune disorder Arterial and venous thromboses Adverse outcome in pregnancy (mother and foetus) Raised titres of antiphospholipid antibodies Primary antiphospholipid syndrome (APS) 50% of patients Secondary syndrome associated with systemic lupus erythematousus (20-35% of SLE patients develop antiphospholipid syndrome) Appears mainly in young women of fertile age Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 22

23 Asherton s syndrome The catastrophic APS It consists of preciptous multisystem organ thrombosis and failure, typically Brain Kidneys Lungs Skin Mortality is 50% It is triggered by pregnancy in 4% of cases Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 23

24 Pathophysiology I The trigger for thrombosis may be pregnancy, infection and local endothelial dammage Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 24

25 Pathophysiology II Antiphospholipid antibodies form a heterogenous group of antibodies directed at plasma proteins that bind to phospholipids In a process mediated by β2-glycoprotein I the antibodies bind to platelets entothelial cells activates complement, finally resulting in activation of tissue factor, endothelial dammage and finally thrombosis In vivo: they are associated with recurrent thrombosis, in vitro: they increase phospholipid dependent clotting times, hence the misnomer lupus anticoagulant Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 25

26 Pathophysiology III Interaction of antiphospholipids with Prothrombin Factor X Protein C and Plasmin Which may impede fibrinolysis Interaction with annexin A5, a natural anticoagulant, may favor placental thrombosis and fetal loss Antiphospholipid antibody binding reduces secretion of human chorionic gonadotrophin (hcg). Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 26

27 Diagnostic criteria The syndrome is present if at least one clinical and one laboratory criteria is met: Vascular thrombosis: One or more episodes of arterial, venous or small vessel thrombosis Morbidity in pregnancy: One or more unexplained death of a morphologically normal foetus beyond the 10th week of gestation Laboratory Lupus anticoagulant on two occasions present Medium or high titre of IgG or IgM anticardiolipin antibody on two occasions Medium or high titre of IgG or IgM anti-β2 glycoprotein I antibody in two occasions Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 27

28 Therapeutic management With proper management more than 70% of pregnant APS women will deliver a viable infant Pregnancy should be discouraged in all women with pulmonary hypertension or a recent thromotic event Close prenatal care with close observation for Maternal hypertension Proteinuria and other signs of pre-eclampsia Close foetal monitoring to assess fetal growth and placental function Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 28

29 Therapeutic management Treatment of choice: Preconceptional low dose aspirin Heparin is usually started in the early first trimester Evaluated: Glucocorticoids offer no benefit Intravenous immunoglobulins are associated with an increased risk of pregnancy loss or premature birth Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 29

30 Medical management Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 30

31 Future therapies Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 31

32 Summary Without antithrombotic treatment during pregnancy the symptomatic APS syndrome is a sword of damocles to mother and foetus During labour anticoagulation becomes a challenge to the obstetrician and the anaesthesiologist APS syndrome is related to all major causes of maternal deaths Hypertensive disorders of pregnancy Embolic disorders and Hemorrhage (because of anticoagulation) Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 32

33 Thank you! Questions? Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 33

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39 Antiphospholipid syndrome, definition Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 39

40 Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 40

41 Antiphospholipid syndrome: Definition & Epidemiology The antiphospholipid syndrome is a prothrombotic disorder that results in both arterial and venous thrombosis and is characterized by the presence of two autoantibodies, lupus anticoagulant and anticardiolipin antibody. The prevalence of lupus anticoagulant and anticardiolipin antibody among patients with SLE are 34% and 44%, respectively The overall prevalence of antiphospholipid syndrome is unclear. In 2007, Hughes predicted that the prevalence of antiphospholipid syndrome will exceed that of SLE. Anaesthesthesiologic management of a parturient with a known antiphospholipid syndrome 41

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